The Bitter Cry of the Children

I

The burden and blight of poverty fall most heavily upon the child. No more responsible for its poverty than for its birth, the helplessness and innocence of the victim add infinite horror to its suffering, for the centuries have not made tolerable the idea that the weakness or wrongdoing of its parents or others should be expiated by the suffering of the child. Poverty, the poverty of civilized man, which is everywhere coexistent with unbounded wealth and luxury, is always ugly, repellent, and terrible either to see or to experience; but when it assails the cradle it assumes its most hideous form. Underfed, or badly fed, neglected, badly housed, and improperly clad, the child of poverty is terribly handicapped at the very start; it has not an even chance to begin life with. While still in its cradle a yoke is laid upon its after years, and it is doomed either to die in infancy, or, worse still, to live and grow up puny, weak, both in body and in mind, inefficient and unfitted for the battle of life. And it is the consciousness of this, the knowledge that poverty in childhood blights the whole of life, which makes it the most appalling of all the phases of the poverty problem.

Biologically, the first years of life are supremely important. They are the foundation years; and just as the stability of a building must depend largely upon the skill and care with which its foundations are laid, so life and character depend in large measure upon the years of childhood and the care bestowed upon them. For millions of children the whole of life is conditioned by the first few years. The period of infancy is a time of extreme plasticity. Proper care and nutrition at this period of life are of vital importance, for the evils arising from neglect, insufficient food, or food that is unsuitable, can never be wholly remedied. “The problem of the child is the problem of the race,”^[1] and more and more emphatically science declares that almost all the problems of physical, mental, and moral degeneracy originate with the child. The physician traces the weakness and disease of the adult to defective nutrition in early childhood; the penologist traces moral perversion to the same cause; the pedagogue finds the same explanation for his failures. Thanks to the many notable investigations made in recent years, especially in European countries, sociological science is being revolutionized. Hitherto we have not studied the great and pressing problems of pauperism and criminology from the child-end; we have concerned ourselves almost entirely with results while ignoring causes. The new spirit aims at prevention.

To the child as to the adult the principal evils of poverty are material ones,—lack of nourishing food, of suitable clothing, and of healthy home surroundings. These are the fundamental evils from which all others arise. The younger children are spared the anxiety, shame, and despair felt by their parents and by their older brothers and sisters, but they suffer terribly from neglect when, as so often happens, their mothers are forced to abandon the most important functions of motherhood to become wage-earners. The cry of a child for food which its mother is powerless to give it is the most awful cry the ages have known. Even the sound of battle, the mingled shrieks of wounded man and beast, and the roar of guns, cannot vie with it in horror. Yet that cry goes up incessantly: in the world’s richest cities the child’s hunger-cry rises above the din of the mart. Fortunate indeed is the child whose lips have never uttered that cry, who has never gone breakfastless to play or supperless to bed. For periods of destitution come sooner or later to a majority of the proletarian class. Practically all the unskilled laborers and hundreds of thousands engaged in the skilled trades are so entirely dependent upon their weekly wages, that a month’s sickness or unemployment brings them to hunger and temporary dependence. Not long ago, in the course of an address before the members of a labor union, I asked all those present who had ever had to go hungry, or to see their children hungry, as a result of sickness, accident, or unemployment to raise their hands. No less than one hundred and eighty-four hands were raised out of a total attendance of two hundred and nineteen present, yet these were all skilled workers protected in a measure by their organization.

It is not, however, the occasional hunger, the loss of a few meals now and then in such periods of distress, that is of most importance; it is the chronic underfeeding day after day, month after month, year after year. Even where lack of all food is rarely or never experienced, there is often chronic underfeeding. There may be food sufficient as to quantity, but qualitatively poor and almost wholly lacking in nutritive value, and such is the tragic fate of those dependent upon it that they do not even know that they are underfed in the most literal sense of the word. They live and struggle and go down to their graves without realizing the fact of their disinheritance. A plant uprooted and left lying upon the ground withers quickly and dies; planted in dry, lifeless, arid soil it would wither and die, too, less quickly perhaps but as surely. It dies when there is no soil about its roots and it dies when there is soil in abundance, but no nourishing qualities in the soil. As the plant is, so is the life of a child; where there is no food, starvation is swift, mercifully swift, and complete; when there is only poor food lacking in nutritive qualities starvation is partial, slower, and less merciful. The thousands of rickety infants to be seen in all our large cities and towns, the anæmic, languid-looking children one sees everywhere in working-class districts, and the striking contrast presented by the appearance of the children of the well-to-do bear eloquent witness to the widespread prevalence of underfeeding.

Poverty and Death are grim companions. Wherever there is much poverty the death-rate is high and rises higher with every rise of the tide of want and misery. In London, Bethnal Green’s death-rate is nearly double that of Belgravia;^[2] in Paris, the poverty-stricken district of Ménilmontant has a death-rate twice as high as that of the Elysée;^[3] in Chicago, the death-rate varies from about twelve per thousand in the wards where the well-to-do reside to thirty-seven per thousand in the tenement wards.^[4] The ill-developed bodies of the poor, underfed and overburdened with toil, have not the powers of resistance to disease possessed by the bodies of the more fortunate. As fire rages most fiercely and with greatest devastation among the ill-built, crowded tenements, so do the fierce flames of disease consume most readily the ill-built, fragile bodies which the tenements shelter. As we ascend the social scale the span of life lengthens and the death-rate gradually diminishes, the death-rate of the poorest class of workers being three and a half times as great as that of the well-to-do. It is estimated that among 10,000,000 persons of the latter class the annual deaths do not number more than 100,000, among the best paid of the working-class the number is not less than 150,000, while among the poorest workers the number is at least 350,000.^[5] The following diagram illustrates these figures clearly and needs no further comment:—

This difference in the death-rates of the various social classes is even more strongly marked in the case of infants. Mortality in the first year of life differs enormously according to the circumstances of the parents and the amount of intelligent care bestowed upon the infants. In Boston’s “Back Bay” district the death-rate at all ages last year was 13.45 per thousand as compared with 18.45 in the Thirteenth Ward, which is a typical working-class district, and of the total number of deaths the percentage under one year was 9.44 in the former as against 25.21 in the latter. Wolf, in his classic studies based upon the vital statistics of Erfurt for a period of twenty years, found that for every 1000 children born in working-class families 505 died in the first year; among the middle classes 173, and among the higher classes only 89. Of every 1000 illegitimate children registered—almost entirely of the poorer classes—352 died before the end of the first year.^[6] Dr. Charles R. Drysdale, Senior Physician of the Metropolitan Free Hospital, London, declared some years ago that the death-rate of infants among the rich was not more than 8 per cent, while among the very poor it was often as high as 40 per cent.^[7] Dr. Playfair says that 18 per cent of the children of the upper classes, 36 per cent of the tradesman class, and 55 per cent of those of the working-class die under the age of five years.^[8]

And yet the experts say that the baby of the tenement is born physically equal to the baby of the mansion.^[9] For countless years men have sung of the Democracy of Death, but it is only recently that science has brought us the more inspiring message of the Democracy of Birth. It is not only in the tomb that we are equal, where there is neither rich nor poor, bond nor free, but also in the womb of our mothers. At birth class distinctions are unknown. For long the hope-crushing thought of prenatal hunger, the thought that the mother’s hunger was shared by the unborn child, and that poverty began its blighting work on the child even before its birth, held us in its thrall. The thought that past generations have innocently conspired against the well-being of the child of to-day, and that this generation in its turn conspires against the child of the future, is surcharged with the pessimism which mocks every ideal and stifles every hope born in the soul. Nothing more horrible ever cast its shadow over the hearts of those who would labor for the world’s redemption from poverty than this spectre of prenatal privation and inherited debility. But science comes to dispel the gloom and bid us hope. Over and over again it was stated before the Interdepartmental Committee by the leading obstetrical authorities of the English medical profession that the proportion of children born healthy and strong is not greater among the rich than among the poor.^[10] The differences appear after birth. Wise, patient Mother Nature provides with each succeeding generation opportunity to overcome the evils of ages of ignorance and wrong, with each generation the world starts afresh and unhampered, physically, at least, by the dead past.

And herein lies the greatest hope of the race; we are not handicapped from the start; we can begin with the child of to-day to make certain a brighter and nobler to-morrow as though there had never been a yesterday of woe and wrong.^[B]

II

In England the high infantile mortality has occasioned much alarm and called forth much agitation. There is a world of pathos and rebuke in the grim truth that the knowledge that it is becoming increasingly difficult to get suitable recruits for the army and navy has stirred the nation in a way that the fate of the children themselves and their inability to become good and useful citizens could not do.^[11] Alarmed by the decline of its industrial and commercial supremacy, and the physical inferiority of its soldiers so manifest in the South African war, a most rigorous investigation of the causes of physical deterioration has been made, with the result that on all sides it is agreed that poverty in childhood is the main cause. Greater attention than ever before has been directed to the excessive mortality of infants and young children. Of a total of 587,830 deaths in England and Wales in 1900 no less than 142,912, or more than 24 per cent of the whole, were infants under one year, and 35.76 per cent were under five years of age. That this death-rate is excessive and that the excess is due to essentially preventable causes is admitted, many of the leading medical authorities contending that under proper social conditions it might be reduced by at least one-half. If that be true, and there is no good reason for doubting it, the present death-rate means that more than 70,000 little baby lives are needlessly sacrificed each year.

No figures can adequately represent the meaning of this phase of the problem which has been so picturesquely named “race suicide.” Only by gathering them all into one vast throng would it be possible to conceive vividly the immensity of this annual slaughter of the babies of a Christian land. If some awful great child plague came and swept away every child under a year old in the states of Massachusetts, Idaho, and New Mexico, not a babe escaping, the loss would be less than those that are believed to be needlessly lost each year in England and Wales. Or, to put it in another form, the total number of these infants believed to have died from causes essentially preventable in the year 1900 was greater than the total number of infants of the same age living in the following six states,—Connecticut, Maine, Delaware, Florida, Colorado, and Idaho. Even if the estimate of the sacrifice be regarded as being excessive, and we reduce it by half, it still remains an awful sum.

Unfortunately, there is no reason to suppose that the infantile death-rate in the United States is nearly so far below that of England as is generally supposed. The general death-rate is given in the census returns as 16.3 per thousand, or about two per thousand less than in England. But owing to a variety of causes, chief of which is the defective system of registration in several states, these figures are not very reliable, and it is generally agreed that the mortality for the whole country cannot be less than for the “Registration Area,” 17.8 per thousand. Similarly, the difference in the infantile death-rate of the two countries is much less than the following crude figures contained in the census reports appear at first to indicate:—

In the English returns the death of every child having had a separate existence is counted, even though it lived only a few seconds, but in this country there is no uniform rule in this respect. In Chicago, for instance, “no account is taken of deaths occurring within twenty-four hours after birth,”^[12] and in Philadelphia a similar custom prevailed until 1904.^[13] Such facts seriously vitiate comparisons of the infantile death-rates of the two countries which are based upon the crude statistics of census returns.

But while the difference is much less than the figures given would indicate, it is still safe to assume that the infantile death-rate is lower in this country than in England. Such a condition might reasonably be expected for numerous reasons. We have a larger rural population with a higher economic status; new virile blood is being constantly infused by the immigration of the strongest and most aggressive elements of the population of other lands; our people, especially our women, are more temperate. All these factors would tend naturally to a lower death-rate at all ages, but especially of infants.

That with all these favorable conditions our infantile mortality should so nearly approximate that of England, that of every thousand deaths 307.8 should be of children under five years of age—according to the crude figures of the census, more if a correct registration upon the same basis as the English figures could be had—is a matter of grave national concern. If we make an arbitrary allowance of 20 per cent, to account for the slight improvement shown by the death-rates and for other differences, and regard 30 per cent of the infantile death-rate as being due to socially preventable causes, instead of 50 per cent, as in the case of England, we have an appalling total of more than 95,000 unnecessary deaths in a single year.

And of these “socially preventable” causes there can be no doubt that the various phases of poverty represent fully 85 per cent, giving an annual sacrifice to poverty of practically 80,000 baby lives. If some modern Herod had caused the death of every male child under twelve months of age in the state of New York in the year 1900, not a single child escaping, the number thus brutally slaughtered would have been practically identical with this sacrifice. Poverty is the Herod of modern civilization, and Justice the warning angel calling upon society to “arise and take the young child” out of the reach of the monster’s wrath.

If our vital statistics were specially designed to that end, they could not hide the relation of poverty to disease and death more effectually than they do now. It is impossible to tell from any of the elaborate tables compiled by the census authorities what proportion of the total number of infant deaths were due to defective nutrition or other conditions primarily associated with poverty. No one who has studied the question doubts that the proportion is very great, but it is impossible to present the matter statistically, except in the form of a crude estimate. There is much of value in our great collections of statistics, but the most vital facts of all are rarely included in them.

In the great dispensary a little girl of tender years stands holding up a baby not yet able to walk. She is a “little mother,” that most pathetic of all poverty’s victims, her childhood taken away and the burden of womanly cares thrust upon her. “Please, doctor, do somethin’ fer baby!” she pleads. Baby is sick unto death, but she does not realize it. Its breath comes in short, wheezy gasps; its skin burns, and its little eyes glow with the brightness that doctors and nurses dread. One glance is all the doctor needs; in that brief glance he sees the ill-shaped head and the bent and twisted legs that tell of rickets. Helpless, with the pathetically perfunctory manner long grown familiar to him he gives the child some soothing medicine for her tiny charge’s bronchial trouble and enters another case of “bronchitis” upon the register. “And if it wasn’t bronchitis, ’twould be something else, and death soon, anyhow,” he says. Death does come soon, the white symbol of its presence hangs upon the street door of the crowded tenement, and to the long death-roll of the nation another victim of bronchitis is added—one of the eleven thousand so registered under five years of age. The record gives no hint that back of the bronchitis was rickets and back of the rickets poverty and hunger. But the doctor knows—he knows that little Tad’s case is typical of thousands who are statistically recorded as dying from bronchitis or some other specific disease when the real cause, the inducing cause of the disease, is malnutrition. Even as the Great White Plague recruits its victims from the haunts of poverty, so bronchitis preys there and gathers most of its victims from the ranks of the children whose lives are spent either in the foul and stuffy atmosphere of overcrowded and ill-ventilated homes, or on the streets, underfed, imperfectly clad, and exposed to all sorts of weather.

For nearly half a century rachitis, or “rickets,” has been known as the disease of the children of the poor. It has been so called ever since Sir William Jenner noticed that after the first two births, the children of the poor began to get rickety, and careful investigation showed that the cause was poverty, the mothers being generally too poor to get proper nourishment while nursing them.^[14] It is perhaps the commonest disease from which children of the working-classes suffer. A large proportion of the children in the public schools and on the streets of the poorest quarters of our cities, and a majority of those treated at the dispensaries or admitted into the children’s hospitals, are unmistakably victims of this disease. One sees them everywhere in the poor neighborhoods. The misshapen heads and the legs bent and twisted awry are unmistakable signs, and the scanty clothing covers pitiful little “pigeon-breasts.” The small chests are narrowed and flattened from side to side, and the breast-bones are forced unnaturally forward and outward. Tens of thousands of children suffer from this disease, which is due almost wholly to poor and inadequate food. Here again statistical records hide and imprison the soul of truth, failing to yield the faintest idea of the ravages of this disease. The number of deaths credited to it in 1900 was only 351 for the whole of the United States, whereas 10,000 would not have been too high a figure.

Seldom, if ever, fatal by itself, rickets is indirectly responsible for a tremendous quota of the infantile death-rate.^[15] In epidemics of such infectious diseases as measles, whooping-cough, and others, the rickety child falls an easy victim. In these diseases, as well as in bronchitis, pneumonia, convulsions, diarrhœa, and many other disorders, the mortality is far higher among rickety children than among others. Nor do the evils of rachitis cease with childhood, but in later life they are unquestionably important and severe. There is no escape for the victim even though the storms of childhood be successfully weathered, but like some cruel, relentless Nemesis the consequences pursue the adult. The weakening of the constitution in infancy through poverty and underfeeding cannot be remedied, and epilepsy and tuberculosis find easy prey among those whose childhood had laid upon it the curse of poverty in the form of rickets.

An epidemic of measles spreads over the great city. Silently and mysteriously it enters and, unseen, touches a single child in the street or the school, and the result is as the touch of the blazing torch to dry stubble and straw; only it is not stubble but the nation’s heart, its future citizenry, that is attacked. From child to child, home to home, street to street, the epidemic spreads; mansion and tenement are alike stricken, and the city is engaged in a fierce battle against the foe which assails its children. In the tenement districts doctors and nurses hurry through the sun-scorched streets and wearily climb the long flights of stairs hour after hour, day after day; in the districts where the rich live, doctors drive in their carriages to the mansions, and nurses tread noiselessly in and out of the sick rooms. Rich and poor alike struggle against the foe, but it is only in the homes of the poor that there is no hope in the struggle; only there that the doctors can say no comforting words of assurance. When the battle is over and the victims are numbered, there is rejoicing in the mansion and bitter, poignant sorrow in the tenement. For poor children are practically the only ones ever to die from measles. Nature starts all her children equally, rich and poor, but the evil conditions of poverty create and foster vast inequalities of opportunity to live and flourish.

Dr. Henry Ashby, an eminent authority upon children’s diseases, says: “In healthy children among the well-to-do class the mortality (from measles) is practically nil, in the tubercular and wasted children to be found in workhouses, hospitals, and among the lower classes, the mortality is enormous, no disease more certainly being attended with a fatal result. William Squires places it in crowded wards at 20 to 30 per cent of those attacked. Among dispensary patients the mortality generally amounts to 9 or 10 per cent. In our own dispensary, during the six years, 1880–1885, 1395 cases were treated with 128 deaths, making a mortality of 9 per cent. Of the fatal cases 73 per cent were under two years of age and 9 per cent under six months of age.”^[16]

These are terrible words coming as they do from a great physician and teacher of physicians. Upon any less authority one would scarcely dare quote them, so terrible are they. They mean that practically the whole 8645 infant deaths recorded from measles in the United States in the year 1900 were due to poverty—to the measureless inequality of opportunity to live and grow which human ignorance and greed have made. Moreover, the full significance of this impressive statement will not be realized if we think only of its relation to one disease. The same might be said of many other diseases of childhood which blight and destroy the lives of babies as mercilessly as the sharp frosts blight and kill the first tender blossoms of spring. The same writer says: “It may be taken for granted that no healthy infants suffer from convulsions; those who do are either rickety or the children of neurotic parents.”^[17] And there were no less than 14,288 infant deaths from convulsions in the United States in the census year. It would probably be a considerable underestimate to regard 10,000 of these deaths, or 70 per cent of the whole, as due to poverty.

It is not my intention to attempt the impossible task of sifting the death returns so as to measure the sum of infantile mortality due to poverty. These figures and the table which follows are not introduced for that purpose; I have taken only a few of the diseases more conspicuously associated with defective nutrition and other conditions comprehended by the term poverty, and, supported by a strong body of medical testimony, made certain more or less arbitrary allowances for poverty’s influence upon the sum of mortality from each cause. Some of the estimates may perhaps be criticised as being too high,—no man knows,—but I am convinced that upon the whole the table is a conservative one. No competent judge will dispute the statement that some of the estimates are very low, and when it is remembered that only a few of the many causes of infantile mortality are included and that there are many others not enumerated in which poverty plays an important part, I think it can safely be said that in this country, the richest and greatest country in the world’s history, poverty is responsible for at least 80,000 infant lives every year—more than two hundred every day in the year, more than eight lives each hour, day by day, night by night throughout the year. It is impossible for us to realize fully the immensity of this annual sacrifice of baby lives. Think what it means in five years—in a decade—in a quarter of a century.

IV

There are doubtless many persons, lay and medical, who will think that the foregoing figures exaggerate the evil. But I would remind them that I have only ascribed 30 per cent of the infantile death-rate to “socially preventable causes,” and only 85 per cent of that number to poverty in the broadest sense of that word.^[C] I have purposely set my estimate much lower than I am convinced it should be. All the facts point irresistibly to the conclusion that even 50 per cent would be a conservative estimate.

In connection with the New York Foundling Asylum on Randall’s Island, it was decided some few years ago to introduce the Straus system of Pasteurizing the milk given to the babies. The year before the system was introduced there were 1181 babies in the asylum, of which number 524, or 44.36 per cent, died. In the year following, during which the system was in operation, the number of children was 1284 and the number of deaths only 255, or 19.80 per cent. In other words, there were 8.03 per cent more children and 48.66 per cent fewer deaths.^[18]

Even more important is the testimony furnished by the Municipal “Clean Milk” depots of Rochester, New York. Some years ago the Health Officer, Dr. George W. Goler, called the attention of the city authorities to the high infantile mortality occurring over a period of several years during the months of July and August. After thorough investigation it was fairly established that impure milk was one very important reason for this high death-rate among children under five years of age. Accordingly the Pasteurization system was introduced. Depots were opened in the poorest parts of the city and placed in charge of trained nurses. After three years it was decided that instead of Pasteurizing the milk obtained from all sorts of places, with all its contained bacteria and dirt, a central depot on a farm should be established and all energies should be devoted to the insuring of a pure, clean, and wholesome supply by keeping dirt and germs out of the milk and sterilizing all bottles and utensils. Strict control is also exercised in this way over the farmer with whom the contract for supplying the milk is made.

Some idea of the important effects of this scientific attention by the Board of Health to the staple diet of the vast majority of children may be gathered from the following figures, which do not, however, tell the whole story. In the months of July and August during the eight years, 1889–1896, prior to the establishment of the Municipal Milk Stations, there were 1744 deaths under five years of age from all causes; in the same months during eight following years, 1897–1904, there were only 864 deaths under five years of age from all causes, a decrease of 50.46 per cent, despite a progressive increase of population.^[19] It can hardly be questioned, I think, that these figures suggest that my estimate is altogether conservative.

The yearly loss of these priceless baby lives does not, however, represent the full measure of the awful cost of the poverty which surrounds the cradle. It is not only that 75,000 or 80,000 die, but that as many more of those who survive are irreparably weakened and injured. Not graves alone but hospitals and prisons are filled with the victims of childhood poverty. They who survive go to school, but are weak, nervous, dull, and backward in their studies. Discouraged, they become morose and defiant, and soon find their way into the “reformatories,” for truancy or other juvenile delinquencies. Later they fill the prisons, for the ranks of the vagrant and the criminal are recruited from the truant and juvenile offender. Or if happily they do not become vicious, they fail in the struggle for existence, the relentless competition of the crowded labor mart, and sink into the abysmal depths of pauperism. Weakened and impaired by the privations of their early years, they cannot resist the attacks of disease, and constant sickness brings them to the lowest level of that condition which the French call la misère.

V

However interesting and sociologically valuable such an analysis might be, the separation of the different features of poverty so as to determine their relative influence upon the sum of mortality and sickness is manifestly impossible. We cannot say that bad housing accounts for so many deaths, poor clothing for so many, and hunger for so many more. These and other evils are regularly associated in cases of poverty, the underfed being almost invariably poorly clad, and housed in the least healthy homes. We cannot regard them as distinct problems; they are only different phases of the same problem of poverty,—a problem which does not lend itself to dissection at the hands of the investigator. Still, notwithstanding that for many years all efforts to reduce the rate of mortality among infants have dealt only with questions of bad housing and of unhygienic conditions in general,—on the assumption that these are the most important factors making for a high rate of infant mortality,—it is now generally admitted that, important as they are in themselves, these are relatively unimportant factors in the infant death-rate. “Sanitary conditions do not make any real difference at all,” and “It is food and food alone,” was the testimony of Dr. Vincent before the British Interdepartmental Committee,^[20] and he was supported by some of the most eminent of his colleagues in that position. That the evils of underfeeding are intensified when there is an unhygienic environment is true, but it is equally true that defect in the diet is the prime and essential cause of an excessive prevalence of infantile diseases and of a high death-rate.

Perhaps no part of the population of our great cities suffers so much upon the whole from overcrowding and bad housing as the poorest class of Jews, yet the mortality of infants among them is much less than among the poor of other nationalities, as, for instance, among the Irish and the Italians. Dr. S. A. Knopf, one of our foremost authorities upon the subject of tuberculosis, places underfeeding and improper feeding first, and bad housing and insanitary conditions in general second as factors in the causation of children’s diseases. In Birmingham, England, an elaborate study of the vital statistics of nineteen years showed that there had been a large decrease in the general death-rate, due, apparently, to no other cause than the extensive sanitary improvements made in that period, but the rate of infantile mortality remained absolutely unchanged. The average general death-rate for the nine years, 1873–1881, was 23.5 per thousand; in the ten years, 1882–1891, it was only 20.6. But the infantile death-rate was not affected, and remained at 169 per thousand during both periods. There had been a reduction of 12 per cent in the general death-rate, while that for infants showed no reduction. Had this been decreased in like degree, the infantile mortality would have fallen from 169 to 148 per thousand.^[21]

Extensive inquiries in the various children’s hospitals and dispensaries in New York, and among physicians of large practice in the poorer quarters of several cities, point with striking unanimity to the same general conclusion. The Superintendents of six large dispensaries, at which more than 25,000 children are treated annually, were asked what proportion of the cases treated could be ascribed, on a conservative estimate, primarily to inadequate nutrition, and the average of their replies was 45 per cent.

In one case the Registrar in a cursory examination of the register for a single day pointed out eleven cases out of a total of seventeen, due almost beyond question entirely to undernutrition.

The Superintendent of the New York Babies’ Hospital, Miss Marianna Wheeler, kindly copied from the admission book particulars of sixteen consecutive cases. The list shows malnutrition as the most prominent feature of 75 per cent of the cases. Miss Wheeler says: “The large majority of our cases are similar to these given; in fact, if I kept on right down the admission book, would find the same facts in case after case.”

VI

As in all human problems, ignorance plays an important rôle in this great problem of childhood’s suffering and misery. The tragedy of the infant’s position is its helplessness; not only must it suffer on account of the misfortunes of its parents, but it must suffer from their vices and from their ignorance as well. Nurses, sick visitors, dispensary doctors, and those in charge of babies’ hospitals tell pitiful stories of almost incredible ignorance of which babies are the victims. A child was given cabbage by its mother when it was three weeks old; another, seven weeks old, was fed for several days in succession on sausage and bread with pickles! Both died of gastritis, victims of ignorance. In another New York tenement home a baby less than nine weeks old was fed on sardines with vinegar and bread by its mother. Even more pathetic is the case of the baby, barely six weeks old, found by a district nurse in Boston in the family clothes-basket which formed its cradle, sucking a long strip of salt, greasy bacon and with a bottle containing beer by its side. Though rescued from immediate death, this child will probably never recover wholly from the severe intestinal disorder induced by the ignorance of its mother. Yet, after all, it is doubtful whether the beer and bacon were worse for it than many of the patent “infant foods” of the cheaper kinds commonly given in good faith to the children of the poor. If medical opinion goes for anything, many of these “foods” are little better than slow poisons.^[22] Tennyson’s awful charge is still true, that:—

Nor is the work of this spirit of murder confined to the concoction of “patent foods” which are in reality patent poisons. The adulteration of milk with formaldehyde and other base adulterants is responsible for a great deal of infant mortality, and its ravages are chiefly confined to the poor. It is little short of alarming that in New York City, out of 3970 samples of milk taken from dealers for analysis during 1902, no less than 2095, or 52.77 per cent, should have been found to be adulterated.^[23] Mr. Nathan Straus, the philanthropist whose Pasteurized milk depots have saved many thousands of baby lives during the past twelve years, has not hesitated to call this adulteration by its proper name, child-murder. He says:—

“If I should hire Madison Square Garden and announce that at eight o’clock on a certain evening I would publicly strangle a child, what excitement there would be!

“If I walked out into the ring to carry out my threat, a thousand men would stop me and kill me—and everybody would applaud them for doing so.

“But every day children are actually murdered by neglect or by poisonous milk. The murders are as real as the murder would be if I should choke a child to death before the eyes of a crowd.

“It is hard to interest the people in what they don’t see.”^[24]

Ignorance is indeed a grave and important phase of the problem, and the most difficult of all to deal with. Education is the remedy, of course, but how shall we accomplish it? It is not easy to educate after the natural days of education are passed. Mrs. Havelock Ellis has advocated “a noviciate for marriage,” a period of probation and of preparation and equipment for marriage and maternity.^[25] But such a proposal is too far removed from the sphere of practicality to have more than an academic interest at present. Simply worded letters to mothers upon the care and feeding of their infants, supplemented by personal visits from well-trained women visitors, would help, as similar methods have helped, in the campaign against tuberculosis. Many foreign municipalities have adopted this plan, notably Huddersfield, England, and several American cities have followed their example with marked success. There should be no great difficulty about its adoption generally. One great obstacle to be overcome is the resentment of the mothers whom it is most necessary to reach, as many of those engaged in philanthropic work know all too well. One poor woman, whose little child was ailing, became very irate when a lady visitor ventured to offer her some advice concerning the child’s clothing and food, and soundly berated her would-be adviser. “You talk to me about how to look after my baby!” she cried. “Why, I guess I know more about it than you do. I’ve buried nine already!” It is not the naïve humor of the poor woman’s wrath that is most significant, but the grim, tragic pathos back of it. Those four words, “I’ve buried nine already!” tell more eloquently than could a hundred learned essays or polished orations the vastness of civilization’s failure. For, surely, we may not regard it as anything but failure so long as women who have borne eleven children into the world, as had this one, can say, “I’ve buried nine already!”

But circular letters and lady visitors will not solve the problem of maternal ignorance; such methods can only skim the surface of the evil. This ignorance on the part of mothers, of which the babies are victims, is deeply rooted in the soil of those economic conditions which constitute poverty in the broadest sense of the term, though there may be no destitution or absolute want. It is not poverty in the narrow sense of a lack of the material necessities of life, but rather a condition in which these are obtainable only by the concentrated effort of all members of the family able to contribute anything and to the exclusion of all else in life. Young girls who go to work in shops and factories as soon as they are old enough to obtain employment frequently continue working up to within a few days of marriage, and not infrequently return to work for some time after marriage. Especially is this true of girls employed in mills and factories; their male acquaintances are for the most part fellow-workers, and marriages between them are numerous. Where many women are employed men’s wages are, as a consequence, almost invariably low, with the result that after marriage it is as necessary that the woman should work as it was before.

When the years which under more favored conditions would have been spent at home in preparation for the duties of wifehood and motherhood are spent behind the counter, at the bench, or amid the whirl of machinery in the factory, it is scarcely to be wondered at that the knowledge of domestic economy is scant among them, and that so many utterly fail as wives and mothers. Deprived of the opportunities of helping their mothers with the housework and cooking and the care of the younger children, marriage finds them ill-equipped; too often they are slaves to the frying-pan, or to the stores where cooked food may be bought in small quantities. Bad cooking, extravagance, and mismanagement are incidental to our modern industrial conditions.

VII

But there is a great deal of improper feeding of infants which, apparently due to ignorance, is in reality due to other causes, and the same is true of what appears to be neglect. In every large city there are hundreds of married women and mothers who must work to keep the family income up to the level of sufficiency for the maintenance of its members. According to the census of 1900 there were 769,477 married women “gainfully employed” in the United States, but there is every reason to believe that the actual number was much greater, for it is a well-known fact that married women, especially in factories, often represent themselves as being single, for the reason, possibly, that it is considered more or less of a disgrace to have to continue working after marriage. Moreover, it is certain that many thousands of women who work irregularly, a day or two a week, or, as in many cases, only at intervals during the sickness or unemployment of their husbands, were omitted. A million would probably be well within the mark as an estimate of the number of married women workers, the census figures notwithstanding. These working mothers may be conveniently divided into two classes, the home workers, such as dressmakers, “finishers” employed in the clothing trades, and many others; and the many thousands who are employed away from their homes in cigar-making, cap-making, the textile industries, laundry work, and a score of other occupations including domestic service.

The proportion of married women having small children is probably larger among those employed in the home industries than in those which are carried on outside of the homes. Out of 748 female home “finishers” in New York, for instance, 658 were married and 557 had from one to seven children each.^[26] The percentage could hardly equal that in the outside industries. While there are exceptional cases, as a rule no married woman, especially if she has young children, will go out to work unless forced to do so by sheer necessity. Dr. Annie S. Daniel, in a most interesting study of the conditions in 515 families where the wives worked as finishers, found that no less than 448, or 86.78 per cent of the whole, were obliged to work by reason of poverty arising from low wages, frequent unemployment, or sickness of their husbands. Of the other 67 cases, 45 of the women were widows, 15 had been deserted, and 7 had husbands who were intemperate and shiftless. Of all causes low wages was the most common, the average weekly income of the men being only $3.81. The average of the combined weekly earnings of man and wife was $4.85, and rent, which averaged $8.99 per month, absorbed almost one-half of this. In addition to the earnings of the men and women, there were other smaller sources of income, such as children’s wages and money received from lodgers, which brought the average income per family of 4½ persons up to $5.69 per week.^[27]